| What is benign prostatic hypertrophy? | Increase in prostate size, no cancer, at transition zone, affects different tissue types including gland.
Symptoms of bladder storage and emptying due to irritation and obstruction (cause lower UT symptoms [LUTS])
Impairs QoL and can cause serious complications.
Hyperplasia of glands of periurethral prostate and not hypertrophy
Symptoms may be stable or worsens rapid, not parallel to histology |
| How is anatomy of prostate? | - The prostate is located in the small (lesser) pelvis just below the bladder. At the front we have the pubis, and in the back the rectum. It surrounds the prostatic urethra
- It has 3 lobes: two lateral lobes united at the front by an isthmus, and at the back by the median lobe
- The median lobe is located above the entrance of the ejaculatory ducts which bring the sperm into the prostatic urethra.
- Lateral lobes tend to increase in volume with age, and the median lobe increases in volume intravesicaly (development up in the bladder)
- The gland is surrounded by a fibro-muscular capsule. |
| Image of Prostate Anatomy. | . |
| Image 2 of prostate Anatomy. | . |
| How is the zonal anatomy of prostate? | 3 Main Zones (central, transition and peripheral zone)
Transition (glandular portion of prostate, in direct contact w/urethra, BPH born in this area periurethral, rarely prostate cancer)
Central (Non glandular portion surrounds transition zone, dense stroma and transition zone, rarely cause of cancer but important role in BPH develops at age 40 in man)
Peripheral Zone (Posterior prostate, in contact with rectum, 80% of gland volume and its the area of prostate cancer)
+ we can add anterior zone closest to abdomen, non-glandular fibromusclar tissue. |
| Image of zones of prostate. | . |
| How is endoscopic anatomy of prostate? | Inside to Outside:
• Trigone and ureteral orifices,
• The median intravesical lobe,
• The hypertrophied lateral lobes,
• The external sphincter and the membranous urethra.
• Verumontanum is the most important marker, the safety limit for the external sphincter.
• The external sphincter begins just below the verumontanum, consisting of circular bands that fold when the cystoscope passes. |
| Image of Endoscopic Anatomy of Prostate. | . |
| How is benign prostate hypertrophy pathophysiology? | Benign, very common, age related condition.
Hyperplasia of transition zone, classically from right and left lobes of prostate but sometimes affects middle lobe on posterior face of bladder neck.
It causes chronic obstacle of bladder emptying w/risk of repercussions on LUT (fight bladder), UUT (chronic obstructive renal failure) |
| How do we get fight bladder and chronic obstructive renal failure? | Dysuria is characterized by detrusor hypertrophy then appearance of trabeculations and vesical diverticula, in final stage when bladder is distended non-functional causes chronic retention w/overflow urination.
Chronic obstructive renal failure (reflux and bilateral dilatation of pelvic calyx cavities can appear)
But No anatomic-clinical correlation, and evolution is not systematically towards appearance of complications, can be latent only functional impairment, never becomes cancer but both are favored by aging. |
| What are risk factors for BPH? | Multifactorial, two most important are age and hormonal status.
Some factors identified (age > 40 years and PSA >1.5 ng/dl) and prostate volume >40g |
| What are clinical presentation for BPH? | LUTS (obstructive [delayed, dysuria, weak jet, late drops], Irritations [Pollakiuria, urgency, urinary burns], LUTS of micturition phase [filling and post]
Severity is assessed by IPSS score, causes impaired QoL, combination with sexual dysfunction is common so it is recommended to assess sexual function in questionnaire. |
| How is DRE in case of BPH? | - Digital rectal examination is systematically performed. It allows to diagnose BPH and to detect a possible prostate cancer associated within the same gland.
- In the case of BPH, digital rectal examination will identify certain peculiarities of the prostate: the gland is enlarged in volume (> 20 grams), it is supple, painless, smooth, regular and is accompanied by a disappearance of
median furrow.
- A rectal examination suggestive of prostate cancer is an indication to perform prostate biopsies with pathological examination regardless of the PSA level. |
| What are acute complications of BPH? | Acute urinary retention (Painful bladder, urge to urinate, tx is urinary drainage placing foli or suprapubic cath)
Infections (prostitis and orchiepididymitis)
Hematuria (initially microscopic, considered BPH complication after elimination of other possible causes)
Acute Obstructive Renal Failure (Acute retention of urine by BPH must be eliminated first) |
| What are chronic complications of BPH? | Chronic bladder retention (usually painless, w/out need to urinate expressed by pt, responsible for urination or overflow incontinence (too full bladder))
Blast Stasis Lithiasis (chornic stasis causes bladder stones causing hematuria or UTIs, seen by ASP and US)
Chronic Obstructive Renal Failure (Bilateral dilation of the pyelocaliceal cavities is chronic and painless. Uretero-hydronephrosis is responsible for thinning of the renal parenchyma and chronic obstructive renal failure ) |
| Summary of Complications | . |
| What is DD of BPH? | ● Neurological bladder.
● Stenosis of the urethra favored by history of urethritis and trauma of the urethra (eg AVP, pelvic fracture, traumatic probing).
● Bladder neck disease.
● Infections like chronic prostatitis.
● Urinary stones.
● Bladder tumors characterized by the presence of hematuria.
Important: Before any hematuria, it is necessary to exclude a bladder tumor by the performing a bladder fibroscopy, and imaging of the upper urinary system. |
| What are complementary exams in BPH? | PSA Rate (detect cancer associated w/BPH, if >4 indication for biopsy, specific for prostate gland but not cancer, can increase w/infection, ejaculation, age...)
Creatinine (evaluate UUT and detects renal insufficiency)
Cytobacterial exam of urine (eliminates any infection presence, can be eliminated by absence of leukocytouria and negative uroculture)
Urodynamic Tests Measuring Flow (debimetry, Measures flow quantifies dysuria, volume must be >150 ml, sees volume, max flow, average flow and mictionnel, bell-shaped curve normal, flattenned is for obstruction/BPH max flow rate 10ml/s)
US (sees repercussion on UUT see bilateral dilations of pyelocaliceal cavities thinning of renal parenchyma, impact on LUT detrusor hypertrophy, bladder diverticula, stones, post-void residue, prostate US transrectal/suprapubic, see volume and median lobe)
Others (bladder fibroscopy, neuro bladder exam) |
| How do we choose the management? | - The different therapeutic alternatives depend on the importance of the urinary symptoms, the appearance of complications, and the patient's preference. The latter must be informed of the different therapeutic options and the advantages and disadvantages of each of them.. |
| What is indication of abstention/surveillance? | Indications: non complicated HBP, SBAU minmal/moderate w/out impaired QoL pt must be educated, informed and reassured about risk of progression of BPH
Dietary and hygiene rules can be introduced mainly reduction of water intake after 18 hours, caffiene and alcohol reduction, constipation tx and cessation of drugs favoring dysuria (anticholinergics, neuroleptics...) |
| What is indication of medical tx? | Indications (uncomplicated HBP, moderate/severe SBAU impairing QoL, symptomatic tx 3 classes: a blockers [be careful of HTA, CAD, elderly], 5 a reductase inhibitors [prescribed prostate >40g, screening requires 2-fold increase in PSA], plants)
medical tx may be combined if ineffective |
| What is indication of surgical tx? | Complicated HBP, SBAU moderate/severe resistant to medical tx, pt preference (it is the only cure, excise the adenoma can still develop from peripheral area left in place, 3 interventions [open surgery supra/retro pubic, cervicoprostatic incision [TUIP], Transurethral resection of prostate [TURP]) |
| What does HBP surgery need? | - Surgery for HBP requires a negative ECBU “Examen cytobactériologique des urines” After resection or enucleation, prostatic adenoma should be sent in anatomopathology in search of prostate cancer. |
| What is TURP syndrome? | Transurethral resection of prostate, rare intraop complication in relation to a large passage of hypotonic fluid into circulation, associates pt w/spinal anesthesia, visual disorders, headache, hypotension, bradycardia, and chest pain, these are related to volume overload and hyponatremia.
Risk factors abundant are intraop bleeding and operation takes >90 mins, tx of TURP depends on natermia
Moderate hyponatremia (>120) : water restriction and diuretics
Severe hyponatremia : hypertonic saline w/slow perfusion but has a risk for central pontine myelinolysis. |
| What are the main chronic complications of BPH surgery? | retrograde ejaculation. Risk varies depending on the intervention: AVH (high adenectomy) > RTUP > ICP (cervicoprostatic incision).
Risk for erectile dysfunction and urinary incontinence are low |
| What are alternatives for BPH surgery? | - As an alternative to standard surgical treatments, new endoscopic techniques such as laser light (green laser light) “photo vaporization laser in French” or holmium laser enucleation (HoLEP), thermotherapy or radiofrequency can also be used. |
| How is paliative tx of BPH? | - In case of failure of the medical treatment, patients with an operative contraindication can be treated either by the insertion of an indwelling catheter or by a urethral stent. |
| How is monitoring for BPH? | - Follow-up of a patient with BPH is done with the help of:
● Interrogation with IPSS score.
● Flow measurement.
● Measurement of post-void residue. |
